General practice workforce supply and training in Western Australia - Optimising Western Australia's prevocational training to support general ...
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General practice workforce
supply and training in
Western Australia
Optimising Western Australia’s prevocational training to support
general practice workforce development
health.wa.gov.auGeneral practice workforce supply and training in Western Australia Version 1.3; 22 January 2018
Contents
Introduction 1
Methodology 2
Background 4
Western Australian general practice workforce supply 6
Workforce shortfalls 6
Workforce maldistribution 8
Changing workforce patterns 11
Role of international medical graduates 14
Implications 15
General practice training in Western Australia 17
Improving prevocational readiness for general practice training 20
Prevocational capacity to meet recognition of prior learning requirements 20
Capacity to train modelling 20
Recommended prevocational generalist training pathway model 25
Consultation 27
Initial consultation 27
Feedback on the Preliminary Report 27
Recommendations 29
Phase 1: Optimising WA’s prevocational training to support general practice
workforce development 29
Phases 2/3: Rural/regional and proceduralist GP workforces 30
General practice project objectives/next steps 31
Appendix A: Summary of modelling methodology 32
Appendix B: Initial consultation 33
Appendix C: Preliminary Report consultation 34
General practice workforce supply and training in Western Australia | iii | General practice workforce supply and training in Western Australia
Introduction
International evidence suggests that countries with a robust primary care sector have better
health outcomes, better equity, lower mortality rates, and lower overall costs of healthcare1.
Effective and accessible primary care facilitates cost-effective, continuous, patient-centred
prevention and treatment that supports individuals to manage their health issues in the
community. A strong primary care sector not only provides better outcomes for patients
through earlier intervention, but it concomitantly reduces preventable presentations and
admissions.
The WA Health Clinical Services Framework 2014–2024 notes the importance of primary
care in the continuum of health care and that Western Australians are using hospitals at
a higher rate than other Australians, including for conditions that could be addressed by a
general practitioner or other primary care provider.
In acknowledgement of the vital role played by general practitioners in the provision of health
care in Western Australia (WA), particularly in rural and remote locations, and issues relating
to the training and maldistribution of the general practice (GP) workforce, the Office of Chief
Medical Officer (OCMO) commenced a project in November 2016 to review and provide
recommendations on GP workforce supply and training issues in WA.
A summary of the review’s initial findings and recommendations were presented to the
Chief Medical Officer (CMO) in March 2017 in the General practice workforce and training
in Western Australia: Preliminary Report to the CMO (Preliminary Report). In July 2017,
the Preliminary Report was noted by the Workforce Steering Committee (WSC), presented
to the WA Health Department Executive Committee (DEC), and its dissemination to key
stakeholders for comment was approved by the Director General.
This report integrates feedback received during that consultation process and reframes the
recommendations of the Preliminary Report in a phased approach for the consideration of
stakeholders, including relevant WA Health committees.
1 Aggarwal, Monica, and Brian Hutchison. 2012. Primary Care Strategy for Canada. Canadian Foundation for Healthcare
Improvement. http://www.cfhi-fcass.ca/Libraries/Reports/Primary-Care-Strategy-EN.sflb.ashx
General practice workforce supply and training in Western Australia | 1Methodology
A number of data sources and stakeholder consultations (see Consultation) have informed
the development of this report including:
* Australian Government, National Health Workforce Dataset, Medical Practitioners
* national GP datasets based on Medicare (Medicare Benefits Schedule primary care and
diagnostics) data
• Australian Government, General Practice Workforce Statistics
• Australian Government, Report of Government Services – Volume E: Health
* Medical Training Review Panel Reports
* Rural Health West (RHW) rural and remote GP datasets
* WA General Practice Education and Training (WAGPET) GP registrar and training
datasets.
Each of these datasets provides insight into aspects of the GP training pipeline and workforce
supply in WA; however none on their own or combined provide a comprehensive integrated
analysis of primary care workforce capacity, demand and service provision. Further data
validation and the development of new methodologies to enhance the accuracy of supply and
demand projections have been planned.
The two key data sources of workforce data are the Australian Government’s national GP
datasets and the National Health Workforce Dataset, Medical Practitioners, which comprises
Australian Health Practitioner Regulation Agency (AHPRA) survey data. This data can
provide for the in-depth analysis of the GP workforce including trends over time, and a
number of such analyses have been provided in this report.
Workforce measures and calculations differ methodologically for each data source and
thus cannot be used interchangeably. This variation means that care must be taken when
interpreting analyses and projections, for example Full Service Equivalent (FSE), Full Time
Equivalent (FTE) and/or headcount have been used by different stakeholders to measure GP
workforce supply. Definitions of key terms utilised in this report are below:
Full Service Equivalent (FSE)
FSE is a workforce measure developed from Medicare data that does not include hours
worked. The FSE measure estimates the total hours worked based on information captured
in the Medicare statistics (number of days worked, volume of services, Medicare Schedule
of Fees). One FSE is approximately equivalent to 7.5 hours per day, five days per week, 48
weeks per year. Of note:
* Medicare data does not capture Royal Flying Doctor Service doctors providing primary
care services, and may not capture all primary care services provided by WA Country
Health Service (WACHS) salaried doctors
* unless otherwise stated, FSE data does not differentiate between the GP services
provided by vocationally registered general practitioners (VRGPs), non-vocationally
registered general practitioners and GP registrars.
2 | General practice workforce supply and training in Western AustraliaFull Time Equivalent (FTE)
FTE is a measure of standard hour workloads for employed health professionals in the
AHPRA survey data and is based on information provided by practitioners for the week prior
to the survey. The number of hours worked are divided by standard weekly hours. For the
medical profession, a standard working week is measured as 40 hours. The AHPRA survey
includes FTE measures for clinical hours, non-clinical hours and total hours.
Headcount
Headcount (national GP dataset) is a count of all doctors providing GP services that have
provided at least one Medicare Service or have at least one claim during the reference
period. Where the headcount is specifically VRGPs this is identified. Headcount (AHPRA
survey) is the number of registered practitioners working in, or on leave from work in
Medicine in the week prior to the survey. Headcount (Specialist Workforce Capacity Program
(SWCP)) is the number of AHPRA registered practitioners identified as working as a general
practitioner in WA at 30 September 2015.
General practice workforce supply and training in Western Australia | 3Background
* WA accessed primary care is lower than the national average and WA had one of the
lowest rates of bulk-billing in Australia in 2015/162
* WA had the second lowest level of Australian Government expenditure on general
practitioners per person (crude) in 2015/163
Whilst further analysis on preventable presentations and admissions in WA is required,
evidence from Queensland Health indicates at least one in 15 hospitalisations in 2013/14
could have been treated in a primary care setting4. Australian Government data indicates that
in WA:
* in 2015/16, there were 66,190 selected potentially preventable hospitalisations (5.9% of
all separations)5, and 337,224 selected potentially avoidable GP-type presentations to
emergency departments6
* in 2014/15, there were 24.3 separations per 1000 population of potentially preventable
hospitalisations and 93.4 separations per 1000 of Aboriginal population of potentially
preventable hospitalisations7.
Despite the benefits of a strong primary care workforce, in Australia there has been a trend
towards sub-specialisation as evidenced in Figure 1 (overleaf). Within the overall growth of
the medical consultants from 2008 – 2012, the increase in the number of non-GP specialists
was 67% compared to a 33% growth in general practitioners8.
2 SCRGSP (Steering Committee for the Review of Government Service Provision) 2017, Report on Government Services 2017,
vol. E, Health, Productivity Commission, Canberra. Table 10A.33.
3 Ibid. Table 10A.2.
4 Queensland Health. 2016. The health of Queenslanders 2016. Report of the Chief Health Officer Queensland. Queensland
Government. Brisbane.
5 Australian Institute of Health and Welfare 2017. Admitted patient care 2015–16: Australian hospital statistics. Health services
series no.75. Cat. no. HSE 185. Canberra: AIHW. Table 4.23
6 SCRGSP. 2017, Report on Government Services 2017, vol. E, Health, Productivity Commission, Canberra. Table 10A.38.
7 Ibid. Tables 10A.84 and 10A.85
8 Australian Institute of Health and Welfare. 2014. Health Workforce Australia 2014: Australia’s Future Health Workforce – Doctors
4 | General practice workforce supply and training in Western AustraliaFigure 1: Australian head count by type of medical practitioner
Source: Australian Institute of Health and Welfare,
Medical Practitioner Workforce Data 2015, Table 12
This trend is reflected in WA where growth between 2013 – 2016 in the non-GP specialist and
GP specialist workforces was 16.2% and 9.2%, respectively.9
Well-functioning health care systems have an adequate number of primary care doctors, an
optimal proportion of primary care to specialty care doctors, and the best possible distribution
of both workforces. While the optimal ratio of primary care to specialty care doctors has not
been precisely determined, it has been suggested that a system in which at least half of its
specialists are primary care doctors provides better health outcomes at lower cost10. In WA
vocationally registered general practitioners in September 2015 represented approximately
42% of the State’s total specialist workforce11.
9 Australian Government, National Health Workforce Dataset, Medical Practitioners
10 WONCA Rural Medical Education Guidebook, chapter 1.2.6 Health Outcomes and the balance of primary care physicians vs
specialists
11 Medical Workforce Branch, Office of the Chief Medical Officer, Department of Health, Western Australia, 2017. Medical
Workforce Report 2015/16.
General practice workforce supply and training in Western Australia | 5Western Australian general practice
workforce supply
There are a number of demographic and other factors relating to the GP workforce that
impact on the current and future availability of primary care in WA and must be considered as
part of GP workforce planning. These include:
* a regionally maldistributed GP workforce
* insufficient GP vocational trainee throughput to maintain current GP service provision,
and considerably less than is required to service future demand
* an ageing workforce with a changing workforce gender balance
* an increasingly part time workforce.
These and other issues are described further below.
Workforce shortfalls
Compared to most other Australian States and Territories, WA’s population has lower access
to primary care services. WA’s ratio of GP FSE to population was 81.5 per 100,000 of
population in 2015/16. This was well below the national average of 96.8, and above that of
only the Australian Capital Territory and Northern Territory (see Figure 2)12.
Figure 2: State and Territory GP FSE-to-population ratios 2015/16
120
GP FSE per 100,000 population
100
80
60
40
20
0
ACT NSW NT Qld SA Tas Vic WA Aus
Source: SCRGSP (Steering Committee for the Review of Government Service Provision) 2017,
Report on Government Services 2017, vol. E, Health, Table 10A.8
12 SCRGSP. 2017, Report on Government Services 2017, vol. E, Health, Productivity Commission, Canberra. Table 10A.8
6 | General practice workforce supply and training in Western AustraliaWA’s GP FSE to population ratio has increased since 2011, as indicated in Figure 3.
Figure 3: WA GP FSE to population ratio 2006/07 to 2015/16
GP FSE per 100,000 population
100
90
80
70
60
50
40
30
Source: SCRGSP 2017, Report on Government Services 2017, vol. E, Health.
In 2015/16, WA had 2695 vocationally registered general practitioners providing 1716 FSE,
while non-vocationally registered general practitioners (n = 531) were providing 294 FSE.13
GP demand modelling is complex and further work is required to validate shortfall figures and
quantify future demand; however, multiple modelling data sources suggest that the VRGP
workforce in WA is insufficient to meet demand, and that existing shortfalls will increase to
2025. Table 1 provides estimated WA general practitioner shortfalls at 2015 and projections
to 2025.
Table 1: WA GP supply and demand estimates/projections to 2025
General practice workforce modelling 2015 2021 2025
Specialist Workforce Capacity Program 2015 (headcount)+ -534 -774 -974
Specialist Workforce Capacity Program 2015+
0 -240 -440
– baseline of zero in 2015
University of Adelaide (FTE)*1 -63 -268 -408
Sources: + Medical Workforce Report 2015/16: Medical Workforce Branch, Office of the Chief
Medical Officer, Department of Health, Western Australia
* University of Adelaide supply and demand modelling dataset, March 2017
Notes:
1. University of Adelaide base year was 2013 with a zero baseline.
2. The SWCP provided a 2015 shortfall estimate based on a 100 GP per 100,000
population ratio while the Adelaide modelling did not.
3. The demand methodology utilised for GP was different to that of other SWCP
specialties and requires further validation.
13 Australian Government, General Practice Workforce Statistics 2015–16 (sourced on 5 September 2017)
General practice workforce supply and training in Western Australia | 7SWCP supply projections, which are calculated assuming a model of self-sufficiency (i.e.
workforce demand is met through the production of sufficient WA vocational trainees), and
modelling undertaken by the University of Adelaide concur that the deficit in the supply of
general practitioners will worsen, due partly to the supply issues outlined in this report.
The SWCP identifies that current levels of GP vocational trainee throughput are insufficient
to meet projected demand for general practitioners to 2025. It has been estimated that WA
needs to source approximately 90 general practitioners per annum simply to maintain current
GP workforce levels, i.e. meet retirement-based demand14. However, the actual headcount
required to maintain current service levels is likely to be higher than this estimate due to the
changing workforce patterns identified later in this report.
The demand modelling figures above do not include the additional supply of medical
graduates from Curtin Medical School (CMS) which will have an intake of 60 in 2016
increasing to 120 in 2022. Issues with prevocational and vocational training capacity that are
described in this report must be addressed if those additional medical graduates are to be
efficiently and cost-effectively progressed through the medical training pipeline into vocational
GP and other specialty training.
Workforce maldistribution
WA has an inequitable distribution of general practitioners within and between metropolitan,
outer metropolitan, rural and remote locations. Areas of saturation such as Perth’s central
and western suburbs (Perth Inner) are contrasted with areas of critical shortage such as
the Pilbara, Goldfields and the Wheatbelt, as indicated in Tables 2 and 3, which provide GP
SPR (i.e. GP specialists per 100,000 population) by metropolitan and rural location based on
SWCP headcount at 30 September 201515.
Table 2: General practitioner to population ratio by metropolitan location 2015
(headcount)
Metropolitan subregions
Perth Metro
Location Mandurah WA total
Perth Perth Perth Perth Perth total total
Inner NE NW SE SW
SPR 172.2 67.43 75.39 69.1 94.59 86.15 74.77 91.26 84.85
Source: Medical Workforce Report 2015/16, Table 19.
14 Medical Workforce Report 2015/16: Office of the Chief Medical Officer, Department of Health. 2017
15 Total number of doctors registered with the AHPRA at 30 September 2015 that were practising and had both ‘General Practice’
specialist registration and principle place of practice within that region.
8 | General practice workforce supply and training in Western AustraliaTable 3: General practitioner to population ratio by rural location 2015 (headcount)
Gold- Great Kimber- South Wheat- Total
Location Midwest Pilbara
fields Southern ley + West belt Rural
SPR 55.75 96.99 141.16 88.19 53.63 92.58 57.6 81.99
Source: Medical Workforce Report 2015/16, Table 21
Note:
+ WACHS have advised that the SWCP headcount methodology has limited validity
as a proxy for primary care access in rural locations. For example, greater than 50% of
vocationally registered general practitioners in the Kimberley are not providing primary care
services but are working as District Medical Officers (DMOs) in WACHS hospitals.
Further evidence of the significantly reduced access to GP services of regional, remote and
very remote communities compared to those in metropolitan locations is provided in national
statistics, see Table 4.
Table 4: General practitioner FSE to population ratio by location 2015/16
Location Headcount FSE FSE/ headcount GP SPR (FSE)
Major cities 2591 1687 0.65 84.5
Inner regional 313 185 0.59 77.5
Outer regional 276 159 0.58 84.3
Remote 207 67 0.32 64.5
Very remote 148 24 0.16 37.7
Total 3535 2122 0.6 81.9
Source: SCRGSP 2017, Report on Government Services 2017, vol. E, Health, Table 10A.21
The data indicates that, with the exception of outer regional which includes several popular
towns in the South West and Great Southern, GP FSE SPR falls as the level of remoteness
increases. Of concern, WA’s very remote communities have a GP FSE SPR that is less than
half than that of its major cities.
It should be noted that while GP SPR can be a useful tool for comparison, it has significant
limitations. For example, within rural (regional) areas the GP distribution is concentrated in
areas of higher population density and does not necessarily reflect population distribution
throughout the region, and headcount GP SPR figures (such as those in Tables 2 and
3) are not indicative of the FTE or FSE of direct primary care services, as some general
practitioners will be providing other services. For example, headcount based GP SPR figures
for the Kimberley, which is classified as ‘very remote’, are distorted by a high population of
general practitioners providing acute care services as DMOs at Broome and Derby Hospitals,
the geographic isolation of towns within the region, and the health profile and transience
of the local population. An example of the differing ratios of DMO to primary care general
practitioners in regional locations is provided in Figure 4 (overleaf).
General practice workforce supply and training in Western Australia | 9Figure 4: General practitioners in the Kimberley and Pilbara by type of service,
September 2015*
Pilbara
Primary care
WACHS DMOs
Kimberley
0% 20% 40% 60% 80% 100% 120%
* Primary care vs District Medical Officer data provided by WACHS December 2017
It should be noted that while GP SPR can be a useful tool for overall data comparison,
it has significant limitations as it does not detail the type of service being delivered by
general practitioners in the rural and remote setting. Confounding factors include general
practitioners working in hospitals and identification of the non-vocational GP workforce
within the total GP cohort
It is recommended that further analysis of the rural and remote GP workforce is undertaken
as a separate body of work, but evidence suggests that WA’s rural and remote general
practitioners work longer hours, and provide more FSE/FTE than their metropolitan
counterparts. WA has 59 solo GP towns and succession planning for this workforce will be
vital16.
WA has significant difficulties in attracting and retaining general practitioners in many of
its rural and remote locations, and is reliant on international medical graduates (IMGs) to
fill supply gaps in some locations. The development of targeted strategies to increase the
number of appropriately skilled rural and remote general practitioners, and improve rural and
remote retention rates, is required to achieve rural and remote GP workforce sustainability.
The Australian Government has approved the appointment of National Rural Health
Commissioner to act as an independent and high profile advocate for regional, rural and
remote health. Any future rural and remote GP workforce project will align with Australian
Government activities and consider the feedback received from stakeholders, including:
* strategies focussed at the beginning of training are essential in influencing students
to consider a career in GP, and encouraging junior doctors to consider the benefits of
training in a rural location
* GP registrars who are immersed in, and training in, rural locations very early in their
training are more likely to stay or return to that location
* additional support to attract and retain trainees and qualified general practitioners where
there are supply issues could include support for further professional development,
including travel, accommodation and course costs, and support for families
16 Rural Health West dataset 15/02/2017
10 | General practice workforce supply and training in Western Australia* efforts to address GP workforce maldistribution have been made with varying
degrees of success through existing jurisdictional rural programs and these should be
considered in conjunction with new innovative workforce strategies. New strategies
include the emergence of telehealth as contributing to primary care supply and training
solutions
* the broad range of factors which combine across Australian Government and State
funded opportunities and which sum to support the attraction and retention of general
practitioners to areas of low supply should be further examined. Remuneration
incentives for trainees and general practitioners could be examined in order to improve
retention
* the development of extended skills is a positive strategy for recruitment and retention
that should be considered as part of the training continuum
* a significant proportion of rural GP services in WA are provided by non-vocational rural
general practitioners
* while IMGs make a very important contribution to the GP workforce, dependence on
IMG recruitment to fill supply gaps in some locations is not a long term, sustainable
solution. An increase in WA’s capacity to educate and train doctors to work in rural and
remote areas where primary care is needed is required
* with a continued need for some IMG recruitment (at least in the short to medium term),
the continued upskilling of this workforce cohort must be supported
GP proceduralists are a GP subgroup that plays an important role in the provision of
extended primary care services at community level in rural and remote locations, as well as
contributing as generalist resident medical specialists at WA’s regional hospitals. WA has the
second highest number of practicing GP proceduralists in Australia, and there is evidence
that GP proceduralists are more likely to be retained in WA’s rural and remote locations than
regular general practitioners.
A separate analysis of GP proceduralist workforce supply and training issues, including
access to advanced GP skills training in WA hospitals, has been identified as a future body of
work.
Changing workforce patterns
Age
The GP workforce in WA is ageing with a significant volume of general practitioners
approaching retirement or a potential reduction in FSE/FTE. AHPRA survey data indicates:17
* the median age of WA general practitioners for the majority of FTE in 2015 was 55
* In 2016 13% of vocationally registered general practitioners were over 65 and they were
providing approximately 251 GP FTE. This represented 11% of all the primary care FTE
in the State. Of concern, these general practitioners could retire at any time.
Table 5 (overleaf) provides the estimated number of retirements to 2021 in metropolitan and
rural/remote locations. Please note the figures are cumulative and assume a retirement age
of 65 years.
17 Australian Government, National Health Workforce Dataset, Medical Practitioners
General practice workforce supply and training in Western Australia | 11Table 5: Estimated GP retirements (headcount and FTE) to 2021
2017 2018 2019 2020 2021
Location Measure
F M F M F M F M F M
Headcount 61 260 76 283 92 317 103 351 123 377
Metropolitan
FTE 45 221 57 242 69 280 78 316 93 344
Headcount 11 73 15 85 17 92 20 100 22 112
Rural / remote18
FTE 9 74 13 88 15 95 18 105 20 120
Source: Australian Government, National Health Workforce Dataset, Medical Practitioners18
The data indicates an estimated 21% of WA’s 2016 VRGP workforce is anticipated to retire
by the end of 2021. This comprises an estimated 500 metropolitan general practitioners at
a loss of 437 FTE, and a further 134 rural/remote general practitioners at a loss of 140 FTE.
Anticipated rural/remote GP retirements to 2021 represent approximately 27% of the total
rural/remote GP workforce in 201619. A request has been made to the Australian Government
for similar FSE data.
Data indicates that in WA the age group with the greatest headcount in 2015/16 was
35 – 44 years (n=916), and the greatest FSE was provided by the age group 45–54 years
(n=590), while the lowest headcount and FSE were in the 65+ age group (n=422 and 221,
respectively), followed by theIn 2015/16 the older GP workforce (>55 years) worked a greater ratio of FSE to headcount than younger general practitioners (
Vocational GP trainees are also embracing less than full time training, with an average 20%
of WA’s AGPT trainees per semester in 2016 and 2017 undertaking their training part-time22.
While WA’s overall ratio of GP headcount to FSE has remained steady, the disparity between
GP headcount and FSE of WA’s home grown GP workforce has increased; In 2000/01, the
average Australian-trained GP was providing 0.58 FSE (approximately 3 days per week), but
by 2015/16 this had decreased to 0.47 FSE (approximately 2.5 days per week) (see Figure
8). Data indicates that in 2015/16 2.1 Australian-trained general practitioners were required
for every 1 FSE of clinical practice23, this is anticipated to increase in line with recent trends
and changing workforce patterns.
Systemwide GP workforce planning and strategies must factor in and make allowances for
changing market trends, both at trainee and general practitioner level.
Role of international medical graduates
Analysis indicates international medical graduates (IMGs) on average provide greater FSE
than their Australian-trained colleagues in WA (see Figure 7). In 2015/16, IMGs comprised
approximately 47% of WA’s GP headcount but provided approximately 59% of WA’s GP FSE.
Figure 7: Western Australian GP headcount vs FSE by place of qualification 2015/16
1244
IMGs
1,676
FSE GP
Head Count
878
Aust/NZ
1,858
0 500 1,000 1,500 2,000
Source: Australian Government, General Practice Workforce Statistics 2015–16
(sourced 5 September 2017)
22 WAGPET, AGPT training distribution statistics 2017.
23 Australian Government, General Practice Workforce Statistics 2015–16 (sourced on 5 September 2017)
14 | General practice workforce supply and training in Western AustraliaIMGs have made an increasingly significant contribution to GP FSE provision in WA since
2000. A comparison of headcount to FSE ratios by place of qualification is included below.
Figure 8: WA GP headcount to FSE ratio by place of qualification 2000/01 – 2015/16
0.80
0.70
GP headcount to FSE ratio
0.60
0.50
0.40
Aust/NZ
0.30 Overseas
0.20
0.10
0.00
Source: Australian Government, General Practice Workforce Statistics 2015–16
(sourced 5 September 2017)
The data indicates that while the headcount to FSE ratio of Australian-trained general
practitioners has decreased since 2000/01, that of IMGs has increased over the same period
from 0.64 in 2000/01, to 0.74 in 2015/16.
WA has largely relied on international recruitment to fill GP supply gaps. As the number of
Australian-trained junior doctors increase, there will need to be a transition towards a greater
degree of self-sufficiency which will need to be judiciously managed. The differing levels of
FSE provided by Australian-trained GPs and IMGs will need to be factored into this planning.
Given self-sufficiency is highly unlikely, and not necessarily desirable, in the short to medium
term interstate and/or overseas recruitment will need to continue to be considered to address
shortfalls in some locations.
Implications
Supply factors impacting on the provision of primary care in WA are:
* an existing shortfall of general practitioners that is projected to increase by the year
2025
* workforce demographics including;
• an ageing GP workforce with a significant volume of approaching retirements
• a changing gender balance as increasing numbers of young female general
practitioners enter the workforce
* a disparity between GP headcount and FTE/FSE, which is anticipated to increase as
the older cohort retire, given younger Australian-trained general practitioners are more
likely to work less than full time
* a fall in average hours worked means there is a need to train a minimum of 2.1
Australian-trained general practitioners for 1 FSE in clinical practice (see above)
General practice workforce supply and training in Western Australia | 15* WA is producing insufficient GP vocational trainees to meet maintenance models
of approximately 90 general practitioners per annum (estimated retirement-based
demand), noting that changing workforce patterns are likely to mean that a greater
headcount will be required to provide the same level of service provision
* reliance on IMG recruitment to full supply gaps in some locations
* the retention rate of WA trainees in the WA workforce is unknown.
GP workforce shortfalls and maldistribution have serious implications for GP primary care
service provision in non-metropolitan locations, and for the training and development of
WA’s future GP workforce. Without strategies to improve the number and distribution of WA’s
Australian-trained GP workforce, WA is at very high risk of:
* being unable to progress the increasing numbers of Australian-trained prevocational
junior doctors efficiently and cost-effectively into vocational training to meet future
workforce demand
* increasing GP workforce shortages resulting in reduced community access to primary
care services, poorer health outcomes, and a potential increase in preventable hospital
presentations and admissions
* increasing numbers of general practitioners failing to achieve fellowship with a full scope
of practice and/or the procedural skills needed to deliver regional rural and remote care,
due to insufficient supervision and a lack of prevocational generalist exposure
* difficulties in transitioning from a dependence on IMG recruitment to a locally-trained
workforce for the provision of GP services in some rural and remote locations.
The shortage of VRGPs for supervision has significant implications for WA’s GP training
capacity and the production of a locally trained, vocationally-registered GP workforce.
The comprehensiveness of primary care provision, for which Australia is internationally
recognised, may be at risk without further workforce development strategies that facilitate a
sufficient supply of general practitioners with an appropriate scope of practice to both meet
future demand in all location types and provide supervision to junior doctors. WA can ill afford
a reduction in the scope of practice of GPs.
GP workforce planning must ameliorate the impact of increasing part time work and
supervision, and improve generalist rotational exposure in prevocational years prior to entry
into GP or any other vocational training programme. Changing population and medical
demographics, and the lifestyle choices of the emerging specialist population are variables
that must be considered, as significantly more general practitioners will be required to
achieve the same level of service as in the past.
16 | General practice workforce supply and training in Western AustraliaGeneral practice training in
Western Australia
* WA is currently progressing insufficient trainees through GP training to meet
maintenance model requirements (approximately 90 general practitioners per annum)
due to high attrition, predominantly in the hospital year of GP training. In 2016 only 86
WA AGPT trainees successfully completed their training
* Capacity to train general practitioners is limited by vocational GP training capacity and
prevocational training exposure to the requirements for entry into GP training
A majority of WA’s new Australian-trained GP fellows are participants in the Australian
Government-funded and managed AGPT. In relation to the AGPT, the Australian Government
has delegated responsibility to:
* the Royal Australian College of General Practitioners (RACGP) and the Australian
College of Rural and Remote Medicine (ACRRM) (the colleges) for
• setting training standards
• assessing AGPT registrars for fellowship
• selection into training for 2018
* Regional training organisations for delivery of AGPT training; in WA this is WAGPET.
GP trainees complete their prevocational training, hospital years and advanced skills training
in WA’s public health system (WA Health) hospitals.
WA Health has acknowledged integrated registrar reform is required to improve systemwide
management of the registrar workforce (vocational trainees and service registrars), and
optimise WA Health’s training capacity with increasing pressure on the vocational training
pipeline due to the increasing numbers of medical graduates. Rotational access to meet
vocational training readiness and to progress in vocational training in all specialties is ad hoc,
siloed and increasingly competitive.
Speciality workforce oversupply needs to be balanced against critical shortages in the
training pipeline where there are competing priorities.
GP has been identified as a priority specialty in terms aligning supply and demand to meet
workforce shortages, and is already a major vocational exit point for WA’s junior medical
workforce as shown in Figure 9 (overleaf)24.
24 General practice vocational trainees in Figure 8 are WA Australian General Practice Training (AGPT) trainees only.
General practice workforce supply and training in Western Australia | 17Figure 9: Proportion of vocational trainees by specialty (>1%) in 2016
3% 3% 9%
6%
6%
3%
Adult Medicine Obstetrics and Gynaecology
4%
3% 8% Anaesthesia Paediatric Medicine (PM)
4% Emergency Medicine Pathology
2% General Practice (AGPT) Psychiatry
Intensive Care Surgery
Medical Imaging Other
49%
Source: Department of Health registrar establishment data and WAGPET data
Of note:
* In 2016 between 42-49% of all vocational trainees in WA were undertaking AGPT with
WAGPET25.
Approximately 180 GP registrars are accepted annually into the AGPT, and about half of
those exit their training as fellows each year. This is due to inflow lag (the allocated intake
until recently was half that of current levels), failure to successfully progress through training,
withdrawals and registrars talking leave during training. WAGPET has identified a number
of specific issues that have significantly impacted the quantity, quality and retention of GP
trainees in WA, such as:
* junior doctors are entering GP training earlier, without the breadth and depth of skills
and experience traditionally gained through years of prevocational experience in a
hospital environment
* college selection into AGPT training is undertaken at a national level, and does not
provide flexibility to prioritise local trainees or necessarily reflect the workforce needs at
a State level
* there are insufficient appropriate training opportunities in the hospital system for
prevocational doctors undertaking requirements for prior learning and procedural
practice. This is further compounded by:
• pinch points in access to core hospital training rotations in anaesthetics, paediatrics,
obstetrics and gynaecology and psychiatry
• attrition in GP training has increased for the following reasons;
-- national AGPT policy change in 2014 with adjustments to leave and maximum
timeframes for completion of training
-- a rapid increase in Australian Government AGPT selection targets have impacted
on the standard of trainees accepted
-- in an increasingly competitive training environment, junior doctors are entering GP
training as a backup vocational career and then departing the program to pursue
other medical careers if the opportunity arises.
25 The proportion varies depending whether senior registrars and/or fellows are included.
18 | General practice workforce supply and training in Western AustraliaStakeholders have noted that many newly qualified general practitioners either lack the
willingness or confidence gained through extensive generalist exposure at prevocational
level to undertake a full scope of practice. This has an impact on their comprehensiveness of
care provision and ability to supervise trainees, and limits their ability to work in regional and
remote locations.
General practice workforce supply and training in Western Australia | 19Improving prevocational readiness
for general practice training
* Current limitations in GP training capacity exist in prevocational resident medical officer
(RMO) rotations that provide readiness for entry into GP vocational training
* In 2016, 18 of 178 AGPT trainees had completed the appropriate hospital prevocational
rotations and were GPT1 ready with recognition of prior learning met (RPL). In 2017, 19
of 178 trainees were GPT1 ready
* It is essential that improved systemwide integration of prevocational and vocational
generalist training occurs to prepare junior doctors for readiness for GP training
* This heralds a potential transition to competence based longitudinal training with further
delineation of GP training readiness
Junior doctors interested in vocational training are currently required to secure for themselves
the appropriate prevocational hospital rotations to gain entry into training, yet both capacity
and training exposure are markedly dissimilar across Hospital Service Providers (HSPs) in
the prevocational space.
* To effectively and efficiently utilise prevocational training capacity, a transition to
systemwide, network based training that is supported by agreed strategic training
principles is essential
Prevocational capacity to meet recognition of prior learning requirements
WAGPET identified that, if training capacity allowed, an optimal matrix of a maximum of six
months in each of the following specialties would provide junior doctors with sufficient time
exposure to enable them to meet RPL; emergency medicine, general medicine, general
surgery, geriatrics, obstetrics and gynaecology, paediatrics and psychiatry.
Training readiness is not only predicated on time based exposure but demonstrated
longitudinal progress and competence achievement during prevocational training. While further
delineation of GP training readiness is required, modelling has been undertaken to identify:
* WA’s training capacity to provide the prevocational specialty rotations that facilitate
junior doctors to achieve GP training readiness
* options for a systemwide ‘generalist prevocational exposure program’ to achieve GP
training readiness for stakeholder discussion, i.e. a facilitated rotational exposure in a
systemwide matrix to aid with access and efficient use of rotations required for RPL.
Twelve modelling scenarios have been explored that would provide prevocational generalist
exposure to improve readiness for GP training for between 100 and 160 junior doctors interested
in GP training. The modelling methodology and limitations are briefly described in Appendix A.
Capacity to train modelling
Modelling was undertaken to identify WA’s rotational capacity to train in:
* seven specialties identified by WAGPET in their preferred matrix for RPL
* five additional generalist exposure specialties that would support junior doctors in
developing generalist skills.
20 | General practice workforce supply and training in Western AustraliaThe number of Postgraduate Medical Council of Western Australia (PMCWA) accredited
prevocational training positions, (training capacity), in WA are provided by specialty in Table
6. It should be noted that not all of these accredited positions are filled.
Table 6: Accredited positions in selected specialties in 2017
Specialty – Secondary / Regional /
Total Tertiary
Outer Metro Remote
Accredited
Positions PGY1 PGY2+ PGY1 PGY2+ PGY1 PGY2+ PGY1 PGY2+
Anaesthetics 0 13 0 13 0 0 0 0
Critical Care 6 70 6 34 0 35 0 1
Emergency 72 191 53 97 13 62 6 32
General medicine 97 143 64 79 20 53 13 11
General surgery 97 66 69 40 14 19 14 7
Geriatrics 25 33 14 6 11 25 0 2
Obstetrics and
0 50.5 0 35 0 9 0 6.5
Gynaecology
Paediatrics 1 34 0 19 1 11 0 4
Psychiatry 26 22 12 4 13 14 1 4
Specialised
Emergency 0 10 0 10 0 0 0 0
Medicine
Specialised
24 126 23 95 1 30 0 1
Medicine
Specialised
24 57 20 33 4 22 0 2
Surgery
Grand Total 372 815.5 261 465 77 280 34 70.5
Source: PMCWA Accreditation Review Table
Notes:
1. Includes all PMCWA accredited PGY2+ positions including positions filled by WA
Health networks and filled by Private Hospitals.
2. Specialties identified by an asterisk were identified by WAGPET in their preferred
matrix for RPL.
3. Excludes accredited positions within the Community Residency Program coded as
CRP
4. Service Improvement and whole sites accreditation (PHS, PPHS and PEHS) lines
have been coded as N/A and are not included in these figures.
General practice workforce supply and training in Western Australia | 21In 2017 there were a total of 815.5 accredited PGY2+ positions available for training in the
selected generalist exposure specialties of which 539.5 were in the seven RPL specialties
identified by WAGPET.
Specialties with limited training capacity, particularly given the competing specialty demands
for training, are highlighted in bold in Table 6. They include anaesthetics, geriatrics,
paediatrics, psychiatry, and obstetrics and gynaecology. All but anaesthetics are
specialties identified by WAGPET as being on their preferred list for RPL.
Capacity and training exposure by selected specialties are markedly dissimilar across WA’s
HSP networks as shown in Table 7 (below) and Figure 10 (overleaf). This phenomenon
impacts on training readiness based on employment factors.
Table 7: Percentage of accredited training positions by specialty and HSP network
% of accredited
Gynaecology
Grand Total
PGY2+ Positions in
Emergency
Paediatrics
Psychiatry
Obstetrics
each HSP network Geriatrics
Medicine
Surgery
General
General
across the selected
specialties (Statewide
and
– Public and Private)1
Fiona Stanley Hospital 45% 26% 24% 23% 21% 12% 26% 28%
Royal Perth Hospital 25% 27% 21% 27% 34% 0% 0% 24%
Sir Charles Gairdner
11% 21% 27% 14% 7% 0% 3% 10%
Hospital
WA Country Health
7% 9% 6% 18% 14% 9% 6% 10%
Service
King Edward Memorial
0% 0% 0% 5% 0% 73% 0% 7%
Hospital
Princess Margaret
0% 8% 0% 0% 8% 0% 29% 6%
Hospital
Ramsay Health Care 9% 6% 12% 14% 17% 6% 15% 12%
St John of God 3% 3% 9% 0% 0% 0% 21% 3%
Grand Total 100% 100% 100% 100% 100% 100% 100% 100%
Source: PMCWA Accreditation Review Table
Notes:
1. Includes all PMCWA accredited PGY2+ positions including positions filled by WA
Health networks and filled by Private Hospitals.
2. Excludes accredited positions within the Community Residency Program coded as CRP
3. Service Improvement and whole sites accreditation (PHS, PPHS and PEHS) lines
have been coded as N/A and are not included in these figures
22 | General practice workforce supply and training in Western AustraliaFigure 10: Accredited PGY2+ training capacity by specialty and HSP network
Specialised Surgery 17 12 17 2 4 5
Specialised Medicine 18 38 27 1 6 18 8 10
Specialised Emergency Medicine 6 4
Psychiatry 5 6 3 4 13
Paediatrics 9 12 10 5 7
Obstetrics and Gynaecology 6 4.5 37 3
Geriatrics 8 7 9 2 4 3
General Surgery 17 18 14 6 5 4 2
General Medicine 64 36 16 10 13 4
Emergency 40 65 13 26 15 32
Critical Care 24 12 17 13 8 5
Anaesthetics 2 6 5
0 20 40 60 80 100 120 140 160 180 200
Fiona Stanley Hospital Royal Perth Hospital Sir Charles Gairdner Hospital
WA Country Health Service King Edward Memorial Hospital Princess Margaret Hospital
Ramsay Health Care St John of God Mount Hospital
Source: PMCWA Accreditation Review Table
Notes:
1. Includes all PMCWA accredited PGY2+ positions including positions filled by WA
Health networks and filled by Private Hospitals.
2. Excludes accredited positions within the Community Residency Program coded as CRP
3. Service Improvement and whole sites accreditation (PHS, PPHS and PEHS) lines
have been coded as N/A and are not included in these figures.
Of note:
* South Metropolitan Health Service and East Metropolitan Health Service have the
greatest overall training capacity, but accredited positions for the different specialties are
concentrated in different HSP networks
* There is significant disparity between networks and therefore lack of equity in access to
training opportunities for GP RPL
* A systemwide approach to prevocational training will provide more training capacity than
a silo model.
The number of RMO rotations available in selected specialties per year, with the maximum
number of RMOs that can be allocated and the minimum exposure per RMO are described in
Table 8 overleaf.
General practice workforce supply and training in Western Australia | 23Table 8: WA capacity to provide generalist exposure rotations (Statewide)
Total no. of Max no. RMOs
No. of Min Exposure
Accredited allocated per
Specialty rotations per per RMO if
RMO annum to min
annum included
positions3,4 exposure
Anaesthetics 13 65 130 0.5 Term
Critical Care 70 350 350 1 Term
Emergency 191 940 940 1 Term
General Medicine 143 715 715 1 Term
General Surgery 66 325 325 1 Term
Geriatrics 33 165 165 1 Term
Obstetrics and
50.5 289.5 101 6 Months
gynaecology
Paediatric medicine 34 160 68 6 Months
Psychiatry 22 111 111 1 Term
Specialised
10 52 Not Available Not Available
Emergency Medicine2
Specialised Medicine1 126 618 618 1 Term
Specialised Surgery 57 281 281 1 Term
Total 815.5 4071.5 3809
Notes:
1. Figure includes 9 neonatology positions at KEMH – These positions should only be
available to those completing basic/advanced paediatric training or a diploma.
2. KEMH ED, NICU and PMH PICU – These are critical and bottleneck rotations for
other training programs.
3. Excludes accredited positions within the Community Residency Program coded as CRP
4. Service Improvement and whole sites accreditation (PHS, PPHS and PEHS) lines
have been coded as N/A and are not included in these figures.
The data indicates that WA does not have the training capacity to meet WAGPET’s preferred
matrix for RPL, but by broadening the number of specialties and taking a systemwide,
strategic approach to the development of a generalist prevocational training program it should
be possible to provide junior doctors with an interest in GP training with the rotations, skills
and experience to achieve GP RPL, as defined by the colleges.
There is sufficient evidence to indicate that a siloed approach will not facilitate efficiency of
training, nor breadth and depth of training necessary for training readiness for GP training. This
is also an issue facing other specialties accredited to undertake vocational training in WA. A
network approach to training appears to be increasingly necessary to optimise WA’s training
capacity to accommodate the increase in medical graduate numbers and progress junior
doctors through the training and employment pipeline into vocational training. Without a network
approach it is likely that progression to achieve RPL will continue to be ad hoc, and inefficient.
24 | General practice workforce supply and training in Western AustraliaMapping speciality requirements for similar rotational exposure to balance workforce need,
and align supply and demand in all 49 medical specialties accredited to deliver medical
vocational training in WA has commenced, integrating the findings of the SWCP. Rotations
with limited training capacity, such as paediatrics and obstetrics and gynaecology, present as
obstacles to progression in training unless a coordinated and systemwide approach is utilised
that balances the training needs of the different specialties.
Recommended prevocational generalist training pathway model
Of the 12 prevocational models explored, the most achievable is a two year generalist
training pathway program that fulfils the training readiness requirements for GP training.
The recommended model, which is described in Table 9, includes rotations of either one or
two terms in emergency medicine, geriatrics, general surgery, paediatrics, obstetrics and
gynaecology, general medicine and leave relief. A term in one of the following, depending
on interest, is also integrated; specialised medicine, critical care, additional paediatrics or
paediatric emergency medicine.
Table 9: Recommended two year prevocational generalist training pathway
Year of program Rotation type (specialty) Length
Year 1 Emergency 2 terms (one tertiary, one outer
metropolitan where possible)
Geriatrics 1 term
General surgery 1 term
Leave relief 1 term
Year 2 Paediatrics 1 term
Obstetrics and gynaecology 1 term
Choice of specialised medicine, 1 term
critical care, additional paediatrics
or paediatric emergency medicine
General medicine 2 terms
The rotational matrix listed above would need to be pre-planned for participants on the program.
In addition to improving the GP training readiness of junior doctors, benefits of the program
may include:
* increased training efficiency within WA Health through the optimal use of training
capacity to progress junior doctors through the vocational training pipeline
* an attractive generalist training for junior doctors which would equip them with a broad
range of skills and experience with certainty in training for the duration of their 3 year
employment contracts as per the ‘Appointment of Interns and Progression to Resident
Medical Officer Policy’ 2017
* a reduction in the significant mid-year attrition of junior medical officers (JMO) including
registrars
* assisting with service registrar recruitment and retention.
General practice workforce supply and training in Western Australia | 25The risks associated with the recommended model include, but are not limited to, securing
agreement from stakeholders, failure to appropriately balance exposure, and the need to
balance the requirements of GP training with those of the other 48 specialties and future
workforce demand/oversupply.
The impact on other training programs and prevocational doctors will need to be carefully
considered and mapped as part of a systemwide approach to optimising system training
capacity.
Stakeholders provided in principle support for the recommended model and noted the
following, which will be further considered as part of further development of a generalist
training pathway:
* rural GPs have special training needs which should be integrated e.g. minimum
emergency intervention and airway management skills
* some trainees should be enabled, either within the two year model or through the
addition of a third year, to complete advanced skills/procedural requirements
* registrar levels rotations could potentially be included to provide junior doctors with
exposure to more independent clinical practice prior to GP training entry
* rotations for prevocational generalist training would ideally include rotations outside
of the hospital based setting in order to optimise training exposure. Such rotations
could potentially be eligible for Medicare support and currently include the Community
Residency Program (WACHS and Silver Chain) and Aboriginal Medical Services
* term allocations are not static, with many allocated terms currently swapped or
abandoned by JMOs. Hence sequestering of rotations for specific training pathways
needs to minimise potential for ‘gaming of the system’
* impact of advocating that selection into GP training occurs after RPL are met, may result
in JMOs enrolling in the appealing GP training pathway who may not be committed to
GP training
* Industrial Relations and employment issues should be clarified and resolved, given the
model requires a networked, rotational approach which would necessitate JMOs moving
between HSPs e.g. access to leave, wellbeing, supervision, complaints processing,
access to and management of mandatory training and occupational health and safety
governance
* potential application of personalised approach to support the progression through
training of less than full time employees
* factoring in national proposals under consideration, including the once yearly
commencement of GP practice, two year internships and the introduction of Entrustable
Professional Activities into the assessment of JMOs
* WAGPET should develop strategies to ensure that GP trainees who are occupying one
of the ‘scarce’ terms, e.g. obstetrics, do not leave early to undertake employment at a
general practice.
26 | General practice workforce supply and training in Western AustraliaConsultation
Initial consultation
Extensive stakeholder consultation (outlined in Appendix B) informed the development of the
Preliminary Report.
There was general stakeholder agreement that GP training and workforce issues within WA
commence in the prevocational training space. Junior doctor representatives indicated in
principle support for a systemwide, networked approach to prevocational training to improve
GP training readiness, acknowledging that further detail and consultation with their peers is
required.
Consultation with WAGPET included the following key discussion points:
* WAGPET has committed senior resources to work with WA Health to develop solutions
based strategies to address issued identified that relate to training, and would;
• provide additional information on competencies required for entry into GP training
• investigate the retention rates of GP alumni in WA.
* The recommended two year generalist exposure model would likely meet the RPL
needs of the colleges.
* WAGPET would consider;
• moving to a single GP registrar commencement. This will alleviate the need for
mid-year recruitment of registrars and residents in the HSPs
• the possibility of accrediting a two year program for training readiness
• provision of access to a Learning Management System – e-Portfolio
• a longitudinal curriculum with competency based training milestones progressing
discussions with the RACGP with regard to selection into training.
Feedback on the Preliminary Report
With the approval of the Director General, the Preliminary Report was disseminated to a
number of key stakeholders who had participated in the initial consultation (see Appendix C).
Stakeholders welcomed the review, and supported the training and GP workforce supply
and maldistribution issues identified in the Preliminary Report. Feedback received has been
integrated, where appropriate, within the relevant section of this Report.
Preliminary Report recommendations made to the CMO were supported and endorsed in
principle by the 15 stakeholders that provided written responses. Stakeholders offered to
engage with the Department as system manager to develop and implement solutions to GP
workforce and training issues presented in the report. Specific feedback included:
* that general practitioners must be supported through their prevocational and vocational
training in the hospital system to practice at the top of their scope, thereby reducing
potentially preventable hospitalisations
* the solution for GP training is likely to involve all junior doctor training in in all hospitals,
and require a centrally coordinated approach to junior doctor and specialty training in
the State.
General practice workforce supply and training in Western Australia | 27You can also read
